Do not code from "probable", "suspected," "questionable," "rule out," or "working diagnosis" or other similar terms indicating uncertainty. If a definitive diagnosis is not known upon the completion of the service, the diagnosis should be listed as the symptoms, signs, abnormal test results, or other reason for the visit.
I just noticed the word inpatient...I'm mostly provider based but, correct me if I'm wrong... In the inpatient setting, if a diagnosis documented at the time of discharge is qualified as "probable," "suspected," "likely," "questionable," "possible," or "rule out," the condition should be coded as if it existed or was established. The basis for this guideline are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
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